Words by Nick Ahlmark, photographs by Nicole Precel
Back in the mid-1990s I was on a gap year before university and had somehow ended up in mid-West America. Wandering through a neighbourhood in La Crosse, Wisconsin, I saw groups of women in brightly-coloured dresses tending to corn crops in their front gardens and washing their clothes in large buckets on their porches.
In one of America's whitest states, this Asian community stood out. I turned to my American friend and asked who these people were? "Oh, they're the Hmong," he replied.
Further questioning revealed that the Hmong are a race of four million people spread out across southern China, Vietnam, Laos, Thailand, Cambodia and Burma. The Hmong of La Crosse are part of the about 180,000 strong refugee community in the US. The Hmong had fought for the Americans against the communists in Vietnam and Laos during the 1960s and 1970s and thus the US had taken in a significant number of Hmong asylum seekers after the Vietnam War.
What struck me on that sunny day in Wisconsin was how this community were dutifully sticking to their traditions. They were even stashing their garden crops in hand woven baskets, all this despite having been in one of the most modern countries on the planet for the best part of 20 years.
Fast forward to February 2011; myself and fellow filmmaker Nicole Precel find ourselves in Chi Ca Commune, a cluster of villages in Xin Man district, part of Ha Giang province in northern Vietnam, the poorest province in the country. We are here to make a film which will become the eighth and final episode of Al Jazeera's Birthrights, a series examining maternal health around the world.
It is the culmination of four months of researching and organising that ultimately enabled us to spend a full eight days in this politically sensitive area of Vietnam that borders China. We were told that this is more time than any other foreign journalist has been allowed in the region post the Vietnam War.
The environment is about as radically different from suburban Wisconsin as one can imagine, but even here, the clash of modernity and tradition is evident. Renowned for its mountains and stunning beauty, the population of Ha Giang province is 90 per cent ethnic minority of which the Hmong make up the second largest group.
Here, in the isolated Chi Ca commune, very few Hmong women choose to use the government-run health services to give birth or seek maternal care. The reasons are numerous and complex, but the first is language. In general, the Hmong do not speak Vietnamese and the Vietnamese do not speak Hmong. As all health workers are from the dominant Vietnamese Kinh ethnic group, this has proved to be a major obstacle.
The second is tradition. The Hmong believe in Shamanism and have a specific set of rituals surrounding all aspects of life and this includes childbirth. It is believed that after the birth, the placenta must be buried in a hole beneath the parents' bed. The babies' bath water must be poured into the hole for one month at which point it is covered up permanently. This tradition ensures the good health of the baby and when the child grows old and dies it must return to collect the placenta for a successful journey to the afterlife. If women give birth at the hospital, conducting this ritual becomes impossible for the Hmong.
The third reason is a lack of trust between the communist institutions and the Hmong. Academics have argued that the Hmong simply pay lip service to Vietnamese nationalism and the communist way. Inside every Hmong mud brick house, a picture of Ho Chi Minh and the communist party flag hangs on the wall. But we very much got the sense that the Hmong would prefer to be seen to conform so as not to cause trouble. That way they can go about their traditional lives but at the same time appease the communist authorities by playing their expected roles without great conviction but with enough diligence.
The fourth reason is distance. The villages of Chi Ca commune are spread out over many kilometres of mountainous terrain. For some pregnant women, getting to the local health centre requires an exhausting trek of up to 10 kilometres. The district hospital is between two and three hours by motorbike, depending on the state of the roads. These journeys are obviously incredibly risky for a heavily pregnant women who is about to give birth.
Vietnam is booming and with the boom has come a massive improvement in health care. Over the last 20 years maternal and infant mortality rates in the urban and low lying regions have improved greatly. But in Ha Giang province the maternal mortality rate is almost 10 times higher than in the more urbanised parts of the country. There are no statistics for Xin Man, but as the poorest district in Ha Giang one can only imagine that the figures are even worse.
Enter the United Nations Population Fund (UNFPA). Realising that cultural barriers are the main obstacles for ethnic minority women seeking professional health care, they have initiated a brilliant and highly successful scheme with the Ha Giang health authority. Targeting the most able and confident young people in local villages, the UNFPA selected 49 ethnic minority women, mostly in their late teens and early 20s, to train as midwives. After the 18 month training programme in Ha Giang's capital, the women return to their villages, provide maternal and infant care to the community and try to convince local women to give birth at either the local health centre or the district hospital.
In Chi Ca commune, 20-year-old Ying, a bilingual ethnic Hmong, is the one taking on the immense challenge of trying to reduce the infant and maternal mortality rates in her community. As you can imagine it is not an easy task and we hope the film illustrates the incredible job she is doing in bridging the gap between the Hmong women and the Vietnamese health authorities.
Having graduated just over a year ago, Ying's presence has already seen an increase in the number of Hmong women seeking to have their babies at the health centre or district hospital. In our short time in Chi Ca we witnessed first-hand Ying convincing, through sheer personality and force of will, two pregnant Hmong women and their families to go to the health centre.
Most Hmong in Vietnam still live off the land. But modernisation throughout Vietnam has been nothing short of thorough and in recent years has reached the most far flung corners of the country. As Vietnam hurtles along the path of economic progress it can only be applauded for attempting to alleviate the pockets of high maternal and infant mortality rates that still remain.
Ying and the 48 other midwives represent a happy medium between modernity and tradition. One can only hope that Vietnam will continue these types of forward-thinking policies in other areas relating to its ethnic minorities, which make up 13 per cent of its over 85 million population, so their ways of life are respected, whilst the nation continues to transform.
Click here to watch The Mountain Midwives of Vietnam.